1. Compression of Morbidity 2006
James F. Fries, MD
Brussels
March 22, 2006

2. Vision and Opportunity
The health of seniors is our greatest national health problem
The health of seniors is our greatest economic problem
We know how to postpone ill-health and infirmity by ten or more years
We know how to moderate medical costs by reducing the illness burden

3. Reduction in Need and Demand for Medical Care
Healthy People Need Less Medical Care
The Health and Economic Solutions are on the Demand Side
The Period of Maximum Employee Vigor may be Extended by Health Enhancement Programs

4. Reduction of Need and Demand Questions Sometimes Asked
Will healthier people cost more by living longer?
What is the length of the lag period between health risk reduction and positive health and cost benefits?
Will we just make people healthier for their next employer?

6. The Compression of Morbidity: Central Thesis
The age at first appearance of aging and chronic disease symptoms can increase more rapidly than life expectancy

7. Scenarios for Future Morbidity and Longevity
Morbidity Death
Present Morbidity 56 76
I. Life Extension 56 80
II. Shift to the Right 60 80
III. Compression of Morbidity 65 77

9. Life expectancy in years
Life expectancy at birth and at 65 years of age by sex:
United States, 90 80 70 60 50 40
Life expectancy at birth
Life expectancy at 65 years
Male
Female
Life expectancy in years
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System.
Chartbook on Trends in the Health of Americans / Health, United States 2005

11. Groups Threatened by the Paradigm of Compression of Morbidity
Bioscientists Fearing Displacement of Funding
Humanists Opposed to “Blaming the Victim”
Geriatricians Worried about Lack of Preparation
Pessimists Believing Goal Unachievable
Demographers Vested in Contrary Predictions

12. Evidence for Compression of Morbidity
Multiple longitudinal studies documenting morbidity compression by social class, exercise level, education level, risk factors for heart disease
Multiple national surveys of disability since 1982
Multiple randomized trials showing disability and cost reductions with risk factor reduction

13. POSTPONEMENT OF DISABILITY The University of Pennsylvania Alumni Statistics
1741 subjects studied over 50 years to age 77
Three groups - low, medium, high risk based on smoking, body weight, and lack of exercise health risks at ages 40 and 62.
The low risk group had only one-half the cumulative lifetime disability of the high-risk group.
Vita et al, NEJM, 1990

14. Cumulative Disability, Mean Values Bars Represent S.E. of the Mean
Disability Index
Vita et al, NEJM, 1998

15. Disability Index by Year and Risk Factor Category
Vita et al, NEJM, 1998

16. Disability Index by Age and Risk Factor Category
Vita et al, NEJM, 1998

17. Running and Osteoarthritis (OA): A 13-Year Study Wang et al, Archives Internal Medicine, November 2002
538 Runners Controls
Average Age 58 in 1984
Followed Annually for:
• Disability • Pain • Osteoporosis
• X-ray Progression of OA

18. Disability by Age and Runner Status
Mean Disability Score
Community Control (n=249)
Runners Club (n=369)
Age Category
Wang et al, 2002

19. Disability | | | | | | | | | | | | | |
0.3 —
0.275 —
0.25 —
0.225 —
0.2 —
0.175 —
0.15 —
0.125 —
0.1 —
0.075 —
0.05 —
0.025 —
0 ---
Disability
Average Age, years
12.8y (95% CI, 8.3 to 20.6y)
8.7y (CI, 5.5 to 13.3y)
4.6y (CI, 2.5 to 7.3y)
| | | | | | | | | | | | | |
Runners (n=370)
Community Controls (n=249)
Postponement of disability (years)

20. National Long-Term Care Surveys Over-65 Disability Distributions (%)
1982
1984
1989
1994
1999
Disabled
26.2
25.3
24.4
22.5
19.7
Mild Disab (IADL)
5.7
6.2
4.8
4.4
3.2
Moderate Disab (1-2)
6.9
7.0
6.7
6.1
6.0
Severe Disab (3-4)
3.0
3.1
3.7
3.4
3.5
Very Severe (5-6)
2.9
Institutionalized
6.8
6.6
4.2
Manton and Gu, 2001

22. Source: Breslow, AJPH, 2006;96:17-19
Self-Assessed Health Status as Excellent or Good: United States,
1991
1995
2000
2001
Total, %
89.6
89.4
91.0
90.8
Age, y
<18
97.4
98.3
98.2
18-44
93.9
93.4
94.9
94.6
45-54
86.6
88.1
88.3
55-64
79.3
78.6
82.1
80.8
> 65
71.0
71.7
73.0
73.4
> 75
66.4
67.8
69.2
Source: Breslow, AJPH, 2006;96:17-19

23. increased unchanged decreased AIDS smoking migraine headaches heart
transplant
suicide
cure
osteoarthritis
exercise
weight loss
Mortality
Morbidity

24. A General Theory of Morbidity and Mortality
Perturbations to the individual health may be classified quantitatively as increasing or decreasing morbidity and as increasing or decreasing mortality
The individual is subject to many perturbations and it is usual for some to have positive and some negative effects
Population morbidity and population mortality are the integrated sums of the positive or negative effects of perturbations on individuals

25. Need and Demand Reduction Randomized Trials in Seniors
Fries et al, Health Affairs, 1998

26. The Key Targets for First Year Health Improvement and Cost Reduction
Perceived Self-Efficacy
Self-Management Skills
High-Risk Persons
Chronic Disease Patients
Last Year of Life
Low Birthweight Babies
Absenteeism
Productivity
Corporate Image
Employee Turnover

27. Conclusions Theory, Longitudinal Studies and Surveys and Scientific Trials document that:
Illness, infirmity, and frailty in populations may be postponed by at least 8 to 12 years
Disability is decreasing by 2% or more per year in many developed countries. Mortality is decreasing at only 1% a year, documenting Compression of Morbidity
Health enhancement programs can improve health and reduce costs in worksites, health plans, and in mature adult populations
Continued Compression of Morbidity is feasible